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Hi, everyone. Um I'm Bianca back for our third session in the Lower Limb Trauma and orthopedic series. Um, and one of the educational reps for which is if you haven't been here before the surgical undergraduate peer teaching alliance scheme. Um And yeah, today I'm joined by George who's going to be presenting for our third session of the series. Um just before I begin. Um, I'd like to thank our sponsors um including the Royal College of Surgeons who has recently sponsored us as well and I'm just gonna hand over to George now. Ok. Hi. Um my name is George. I'm 1/5 year medical student at UCL and um actually I'll just share my screen. Um, can everyone see my screen? Yeah, we can see it. Great. So, yeah, uh today I'll be um teaching on. So the lower limb conditions I know you guys might um have had attended the previous two se uh sessions which were on a lower limb anatomy. So this will focus more on kind of clinical cases and clinical conditions. So a bit more relevant to your kind of 4th, 5th year and sixth year exams. Um So yeah, once again, those are our sponsors. Ok. So what are we gonna cover today? Um So today we're gonna cover the acutely swollen joint and what things can cause that. So that's things like septic arthritis, gout, pseudo gout and uh hemo arthrosis. Um Then we're gonna cover some of the uh most common orthopedic emergencies. So things like compartment syndrome and open fractures, um then we're gonna cover some of the most common fractures of the lower limb, in particular hip fractures and ankle fractures, which med schools like to examine on as a lot and also knee, knee injuries, mainly the soft tissue injuries. So, ACL tears and meniscus tears and then we're gonna cover some of the most common conditions of the foot. So, achilles, tendonitis, plantar, fasciitis and helix valgus. And then we are going to um go over osteoarthritis in the hip and the knee. Ok. Ok. So firstly, um the acutely swollen joint. So the acutely swollen joint, which we can see on the picture in this case, it's the right knee is a very common presentation um to Ed. And a lot of times when you're on F one and you're in the Ed and you're presented with this. So what do you do? So it can be caused by different conditions? So, septic arthritis, uh crystal arthropathy and also hemo arthrosis, which is basically blood in the joint. So if you're an F one and Ed and someone comes with the acutely swollen joint, what do you do? Um, so the approach we take is like with any condition, you want to take a good history, you want to know whether there are any, um, any kind of signs or any history of trauma. Um, then you want to know their past medical history. Do they have any osteoarthritis gout, pseudo gout? Uh, also very important that you ask about, um, previous, about their previous surgical history as well, whether they've had any previous joint replacement. So that's also very important because people with the joint replacement you're worried about is that joint replacement infected? Um Next, you want to ask whether they have any systemic symptoms, so any fevers. Um So if someone has an acutely swollen joint and has a fever, you're very highly suspicious of septic arthritis. And um, yeah, and we'll talk about that in a bit. Um So what investigations do you wanna do? So if they're unwell, like any unwell patient, you want to do an at e assessment, you want to examine their joints. Um And then you wanna do some bloods, you want to do some full blood, uh F PC, use the knees CRP and ESR and you wanna do some imaging as well. Uh Usually that's an X ray. Um However, the most important thing that you want to do is a joint aspiration. So we can see from the picture on the right here that a joint aspiration is basically you want to kind of stick a needle into that joint and remove the fluid. Um Usually this can be done at the bedside. However, um if they've had a joint replacement before, um you wanna basically, you wanna take them to theater, you wanna do it in a sterile environment because you don't wanna introduce anything into that joint. Um Once you've aspirated that fluid, you want to send that fluid off to the lab and you want to analyze it for crystals, you want to do a gram stain, uh an MC NS and also a white cell count. So, what is septic arthritis? Um So basically, when someone presents with a fever and septic uh and also an acutely swollen joint, it's pretty much septic arthritis until proven otherwise. So you want to have a very because it's quite a serious condition. You want to have a very low threshold um for diagnosing it. So what is it? It's an infection of the joint. So it's usually spread through um the bloodstream from another part of your body. Um This is what we call hematogenous um spread, but it can also be spread um directly via penetrating injury as well. So, the most common cause is staph aureus. This is the most common cause in adults. And we can see that's just on the top right picture. You can see that um the bacteria stain purple, so it's gram positive and it's round shaped. So it's a cocky and it's in a cluster. So, staph aureus, um you also have to be um in more uh sorry in younger sexually active patients. Um, Neer gonorrhea is also quite a common cause as well. So that's in the bottom picture. You can see that stains um pink. So that's gram negative and it's also cocky but it's been, if you can see closely it's in two. So it's a diplococci. Um So nera gonorrhea and one thing that you need to be aware of for your exams as well. Um A couple of past my questions on this as well is that for in those patients with sickle cell disease, salmonella can also cause septic arthritis as well. Um So what are your features? Once again, it's single, um swollen joint, usually quite painful as well and usually they present with a fever. However, if they don't prevent uh present with a fever, it does not rule it out. Um And on examination. So, yeah, it's red, swollen warm and it's painful on movement as well. So, uh what do we wanna do? So we kinda covered this before. So, investigations you wanna do uh bloods and blood, uh blood cultures. Um your this is because um se arthritis in its name, it can cause sepsis and you wanna do joint aspiration and you wanna send that off uh for fluid analysis. Um So how do we manage it? So, pretty much you wanna start empirical broad spectrum antibiotic treatment as soon as you've done the joint aspiration. Um, so first line is usually flucloxacillin. Um, and if they're penicillin allergic, you wanna give him clindamycin. Um, it's quite a long course of antibiotics, usually for a total of six weeks. So usually you have two weeks of IV antibiotics and then you can switch them to oral antibiotics after those two weeks. Um So you also want to let the, I mean, so definitely you want surgeons to review anyone that you suspect has septic arthritis, you want the surgeons to review them because most likely other than antibiotics, they would like to do a joint wash out as well, which you can see in the picture kind of basically using saline to wash out the joint just to make sure you've gotten rid of, you know, all the bad stuff in the in that joint. Ok. So next we're gonna cover gout. So gout is a crystal arthropathy and it's due to a collection of monosodium urate crystals in the joint and it's usually caused by chronic hyperuricemia. So that's just uh high levels of urate in the blood. Uh Commonly, it was referred to the disease of the Kings due to back in the day kings used to like to overindulge in things like food, um alcohol. Um in terms of food, it would be things like um food that was rich in purines. So it's things like shellfish, red meat, alcohol, all these types of food are quite rich in purines and purines in the body are broken down into a urate. So it increases the amount of urate in your bloodstream. Also things that can um that decrease the amount of uh uric acid that's excreted, um can also increase your likelihood of gout. So things like C KD use of diuretics as well. So the features, how does it usually present? So if you can see on the right uh the picture there, it classically uh affects the big toe. So that's the first MTP joint, but it can also affect other joints. But characteristically, it affects that and it's usually red, painful and swollen. It um usually episodic as well. Patients can have flare ups that last for a couple of days and get well and then have another flare up. And um so what you do is once again, you'd want to do joint aspiration and do microscopy. So, in this case, um well, the thing that you need to remember for your exams pretty much, right, learn is that um classically gout is needle shaped, negatively birefringent monosodium urate crystals under polarized light. So what that means is that if you can see the crystals well, they're needle shaped, we're gonna compare this to pseudogout in a bit, but they are needle shaped and also um they um what negatively birefringent means is when polarized light is shone through it. Um So basically light with a direction is shown. So when it's shown in parallel to the direction of the crystals, it turns yellow. Ok. So, and, and an X ray as well. If you do an X ray, if someone gets repeated attacks of gout, um in severe cases, it can show punched out kind of lesions of bone. So how do we manage it? So we manage it by um during an acute attack or an acute episode, you can give him nsaids like naproxen or Ibuprofen or you can also give him colchicine. But you wanna be careful with that because that can cause diarrhea. Um How do we prevent episodes is that we wanna do some lifestyle modifications? So things that um so like improve your diet, reduce your diet, um like reduce your consumption of things that are high in purines and you can also do and give them allopurinol, which is basically a drug that helps to reduce the amount of urate in your blood. However, when you do give that um give this drug to them, you also want to give them colchicine as well because um giving it can often actually provoke an attack of gout. So you just wanna give that colchine cover to make sure it doesn't provoke an attack of gout. Um So pseudo gout, um so pseudogout, light gout is also another one of those crystal arthropathies. Um they're caused by deposits of calcium pyrophosphate crystals um which is in comparison to the um the urate crystals in gout So it's different chemical. So it's calcium pyrophosphate crystals um in the joint. So risk factors include things that pretty much increase the level of calcium in your blood. So things like advanced age, hyperparathyroidism, hemochromatosis, things that increase the level of calcium. So how does it usually present? So it more commonly affects your proximal joints. So things like your knees, your wrist, that's in comparison to gout, which affects your more distal joints, like your big toe and it mimics scalp. So it's red, presents red, hot swollen joint. So what do you do again? So you do joint aspiration and microscopy. However, in this case, it is positively birefringent, rhomboid shaped crystals. So uh what this means again. So as you can see from the picture here that it is rhomboid shaped and positively birefringent means that when you shine po a polarized light through it, it turns blue. And if you do an X ray as well, um you get a sign called chondrocalcinosis, which you can see that the arrows point to it uh towards it. So this is basically when you get calcium deposits in the cartilage. In this case, it's the meniscus. And if you get calcium deposits, basically the cartilage starts to turn into bone. So it becomes more dense and it shows up more white on an X ray. So management is similar to gout as well. So you give nsaids and you treat the underlying cause. OK. So next, we're gonna talk about hama arthrosis. So this is basically bleeding into the joint cavity. Um causes usually due to trauma and however, you can get it in nontraumatic cases. And it's more common in people with bleeding disorders, especially those with hemophilia or on anticoagulants. Um So features, once again, it presents acutely swollen joint usually following trauma. So what you wanna do uh investigation wise is you wanna do blood in particular, you wanna do a clotting screen to kind of see whether they have any of these bleeding disorders. You want to do an imaging, you can do X ray and on joint aspiration pretty much when you aspirate, you get blood. So a diagnosis can be made that way. So once you stick the needle in and you aspirate blood comes out. So, hemo arthrosis, um how do we manage it? Usually it's quite conservative. So you rice um so you give rest. Uh so you rest um ice, compress uh compressed, compression and elevator. Do you wanna give them sufficient analgesia? Cos it can be quite painful and if they do have any coagulopathy, do you want to correct that? So next, we're gonna cover um some orthopedic emergencies. Ok. So the first one we're gonna cover is compartment syndrome. So sorry um compartment syndrome. So what it is is a rise in pressure within a closed anatomical space. So in the lower leg, um we have four compartments. So just as an example on the lower leg, we have four compartments in each compartment is usually a couple of muscles and their blood supply and also their nerve supply as well. And within each compartment is surrounded by fascia. And so what happens is if you get a rise in um ari pretty much a rise in this pressure within this compartment, you get compartment syndrome. So it usually occurs after the after high energy trauma, crush injuries, fra and fractures that cause vascular injury. Some of the most common fractures that cause this include tibial shaft and supracondylar fractures. So what's the pathophysiology behind it? So, pretty much you get local trauma and soft tissue destruction, you get bleeding and edema. So you pretty much you get fluid flowing out of the muscle cells into the interstitial space, you get increased interstitial pressure, um then you get vascular occlusion. So you get decreased venous outflow relative to the arterial outflow and this leads to myoneural ischemia. So this ischemia to the muscles and to the nerves as well. So what does this cause? This ischemia causes pretty much pain? What you need to remember is pain. So these patients um the pain is very, very severe, severe. So you give them a whole lot of morphine, you give them a lot of analgesia and they're still complaining of pain. So, in those patients, you want to be very, very suspicious of compartment syndrome. So it is an um emergency. Um So it's pain that is usually once again, disproportionate to the injury, made worse on passive movement and does not respond to analgesia. Um, just because if you can still feel the pulses, it doesn't mean it's um uh it doesn't mean that it's not compartment syndrome. And um if untreated, it can cause the six ps, which I don't know, some of you may have done your vascular surgery placement if not. Um, the six ps is what happens when you get ischemia to a limb. And those include your pallor um perishing, cold paraesthesia, um pain. And for the other two pa PAA paresthesia, perishing called I forgot the other two. But uh you can look those up later. But what pretty much those things are quite late later on in the process. And once those things happen, you're unlikely to be able to salvage the limb and will most likely require um amputation. So, how do we investigate it? Um So normally it's a clinical diagnosis. Um But to confirm that you can do um intracompartmental pressure monitor, which we can see on the lower left. And that can be used basically, that's a needle and you stick it into that compartment and it measures the pressure within that compartment. If a pressure is above 20 it uh you kind of think something's going on here and if the pressure is above 40 then it's diagnostic of compartment syndrome. But usually it's a clinical diagnosis and the reason why is it's urgent, you need to recognize it urgently and you need to urgently send them into surgery and how we treat it is we do a fasciotomy. Um So that's basically where you cut a hole or a slit into the fascia and you relieve that pressure within that compartment. And w you can also whether there depends on whether there is a large amount of dead tissue. Uh You wanna de uh you wanna do a debridement as well to pretty much get rid of that dead tissue if there is. So um after surgery, you want to monitor the renal function because it can cause rhabdomyolysis. Um because um muscle is getting broken down, it releases creatinine kinase and this can affect your kidneys. So you want to be quite cautious of that. So compartment syndrome is a very urgent surgical emergency. You wanna have a low clinical suspicion for this and if you suspect it, you wanna let the surgeons know and they, it needs to be operated on as soon as possible. So the next thing we're gonna cover the next slide is it's quite graphic. So if you do want to look away, I would suggest for maybe the next two minutes or so, do look away but it's on open fractures. Um So open fractures. Well, what is an open fracture? So an open fracture is any fracture plus a break in the skin. So that fracture is now open to the environment and it's very susceptible to infection. Um It's usually associated with um damage to surrounding tissues such as nerves, vessels and muscles as well. And so how do we manage it? So, this is taken from the British Orthopedic Association and these guidelines say that these patients ideally are taken to a hospital that have joint orthoplastic care. So uh care between a combination of orthopedic surgeons and plastic surgeons. So when they come in, you wanna do an a ta assessment and you want to resuscitate them. So that's, you know, if they need fluids, if they need pain medication, so give them that and you wanna give them prophylactic antibiotics, usually quite broad spectrum antibiotics and ideally within one hour of the injury, um then you want to kind of examine the joint. So it's very important that you kind of assess and document the neurovascular status and whether there's any contamination to the wound. Uh You, you want to take photographs of the open wound before you do any kind of debridement. And throughout your entire process, you want to take photos as well and you wanna document, um you also want to urgently reduce the fracture and splint it. And then as soon as you've done that, you can reassess your neurovascular status and you might wanna consider doing a trauma ct. Um So how do we manage it? So, more definitive management. So what we covered just before was more kind of acutely how you manage it So, um how you wanna manage it. Um uh definitively is usually you wanna do some sort of fixation and you want to have some sort of skin coverage. So that's why you want that combination of orthopedic and plastic surgery care. Um So you want a debridement, do a debridement as well, which is removal of the dead tissue and you want to do a wound wash out. So the garden suggests that if it's a highly contaminated or vascularly compromised, you want to do the wound debridement and wound washout immediately. So this is things like if you, it's contaminated by sewage, water or things like that, you wanna do it immediately. If it's a high energy fracture, you wanna do it within 12 hours, if it's low energy within 24 hours, but ideally as soon as possible. So once that's done, you basically want to have a clean surgery next. So that means fresh instruments, people need to rescrub and reprep re drape as well because once, then once you're actually operating you, yeah, you don't wanna contaminate the wound again. Once you've cleaned it, you don't wanna contaminate again. Um So in this case, you wanna stabilize the fracture, usually, uh it's external fixation which you can see on the picture. So kind of all the metal bars and the screws are going into the um the bone and you can see it on the outside and you usually do this over internal fixation. Um because it's usually a less risk of infection and you can kind of modify it and um later down the line as well. And it also allows for better healing as well cos in internal fixation. Um So if you have external fixation, it doesn't interrupt the blood supply as much. Um However, in some cases, the limb is not salvageable and you might require amputation and, but this is not something that you need to be concerned with. It's usually MDT decision made by the surgeons as well. So next, we're gonna cover some of the most common fractures of the lower limb, in particular, we're gonna cover hip and ankle fractures. So these quite commonly um come up in, you know, both SBA S and Aussies as well. So, yeah, so it comes up and uh and exams a lot. So the types of fractures, uh we want to be aware of uh intracapsular and extracapsular fractures. So, intracapsular fractures are any fractures pretty much above these, this intertrochanteric line. So you have the greater trochanter hair and the lesser trochanter hair. If you imagine a imaginary line going there, that's the intertrochanteric line. And pretty much anything above that is a intracapsular fracture. Anything below that is an extracapsular fracture. This is because the joint capsule usually wraps around the femoral head and attaches to that line though. Uh why this is important is because fractures, especially what we call neck of femur fractures, which is a fracture of the femoral neck, which is an intracapsular fracture. Um The femoral head has a retrograde blood supply. Um So we can, if we can see on the picture on the right, this means that kind of the blood supply to the femoral head comes from below. So from the medial circumflex, from the lateral circumflex and it hits upwards through the um the femoral neck and supplies the femoral head. So if you get a neck, a femur fracture, you disrupt that blood supply and it can cause avascular necrosis which is very, very bad. Um So hip fractures. So if we cover neck of femur fractures, now, if we focus on those, now it's a very common orthopedic presentation, often more common in elderly osteoporotic women. Um They have actually very, very high mortality rate, uh 30% at one year. And this is due to complications such as infection such as um avascular necrosis. And also that the patients that I usually have uh that present with the neck of feur fracture are usually quiet, quite frail, um quite old have very um also quite commonly have other comorbid conditions as well. So the mortality rate is quite high. Um So the cause is usually a fall, um usually in a frail patient, but it can also be caused by high energy um injuries as well. So features classically uh it's pain and instability and, and, and uh and you, they usually are unable to weight bear on that side, on examination, uh that the side of the injury there, it is usually that limb is usually um classically shortened and also externally rotated. Um This is due to the pole of the I Os muscle. So it kind of pulls it in and so it causes it to be shortened and externally rotated. Um The classification that med students need to know is the garden classification. So it's sorry that it's a bit blurry. But um on the picture on the top, um type one pretty much means it's an incomplete neo feur fracture. Type two is a complete fracture complete throughout uh through the neck, but there's no displacement. Um Type three is a complete fracture, but there's a minimal amount of displacement and type four, the most severe is when there is a complete fracture and there's also uh displacement as well. So, displacement, meaning uh the proximal and the distal section of the bone is completely separated from each other. So what investigation we wanna do? We wanna do a plain pelvic x-ray. Um Usually you want two views as well, but this one that we have on here is an AP view. And on this X ray, we can see that on the right side, everything looks normal. Um We can see that there's no disruption to shin's line. Whereas on the kind of left side here where you can clearly see that there's something sorry, you can clearly see that there's, there's something wrong here. There's a disruption to shin's line here and you can see the fracture hip. So that is, that would be a type four me a feur fracture. So once again, a complication, if the fracture is displaced, it can disrupt the blood supply and cause avascular necrosis. So how do we manage it? So we like any animal patient wanna get uh do an at assessment, you can uh and stabilize the patient, you wanna give them adequate analgesia. Um What we, what surgeons like to do is what we call a fascia iliaca block. So that's basically you inject um some local anesthetic into the um basically fascia iliaca, which is basically a compartment with an kind of your um groin region and this compartment contains your femoral nerve. Um So if you inject local anesthetic in it, it gives kind of good local control of the pain that um so the goal of surgery is to pretty much allow immediate weight bearing as soon as you've um done the surgery. So you want them to kind of weight bear on that side as soon as you're done after surgery. And this is to minimize complications and promote healing. So, if it's an undisplaced nrem fracture, um we usually do internal fixation using screws. Uh cos often in this case, the blood supply is not disrupted. Whereas if it's a displaced neck or femur fracture, you usually do a hemiarthroplasty or a total hip replacement or total um arthroplasty. So we can see on the image here, a total hip arthroplasty is when you both replace the femoral hip and also the acetabular hip. So you wanna replace both. So it's a much larger surgeries. Um Whereas a hemiarthroplasty is, you don't actually replace the acetal in here, you just replace the femoral head. So in which cases do you do, which, so if they have a good premorbid status, so if before the fall, they were able to walk independently, they didn't need a stick or a Zimmer frame, they weren't cognitively impaired, they were quite fit. Then usually you'd do a total hip replacement. Um The only thing is is that total hip replacements don't last forever. So they last about 15 to 20 years. So if you do one in quite a young patient, let's say when they were 5060 then it's gonna last 1520 years. So after that, you're going to either do another one or you're gonna need another revision as well. So in that case, in younger patients, we can mm we can give them the option of internal fixation as well. So to use kind of screws and hope it works. But if it does fail that we can then convert it to a total hip replacement. Um But if they have a poor periorbit status, they're unable to walk, they're cognitively impaired. They're medically unfit for, for the procedure, we just stick with a hemiarthroplasty. So we only replace the femoral head. Um So how do we manage extracapsular fractures? So once again, these are fractures that are below the intertrochanteric or involve the intertrochanteric line. So if it's a intertrochanteric fracture, so this is a fracture between the uh greater trochanter and the lesser trochanter. Usually you would do what we call a dynamic hip screw. So we can see uh this picture here on the left. That's what we call a dynamic hip screw. So this type of surgery, it pretty much requires weight bearing. So compression can be achieved across the fracture site. And that's how uh it uh stabilizes the fracture. Um any other fracture. So any oblique fracture, which is kind of a diagonal fracture like this, a transverse or subtrochanteric fracture. So any fracture below you want to do intramedullary nailing. So which is picture b or the picture on the right hip. Um What we do see however, is that dynamic hip screws, we don't really do those anymore. And we're moving towards pretty much intramedullary intramedullary nailing everyone because it's usually a quicker operation and the incision is smaller. So pretty much anyone with extracapsular fracture, we want to in um use an intramedullary nail to provide um internal fixation. Um So next, we're gonna cover ankle fractures, which is also a common exam topic. So it's a very common injury more common in younger males and also older females. So just to rise ana an ankle anatomy. So the ankle is basically a articulation between the end of the tibia hair and the end of the fibula and also the talar bone pet. Um We also need to note that the tibia and fibula um are joined by syndesmosis, which is basically fibrous tissue that joins the tibia and the fibula. So it's usually an anterior uh syndesmosis and posterior syndesmosis here. Um Also in the ankle, we refer to on the tibial side or on the medial side as the medial malleolus and on the lateral side, on the fibular side, it's the lateral malleolus and kind of the calcaneus here. That is um the posterior malleolus. So for an ankle fracture, we can get an isolated lateral malleolus fracture. You can get a isolated medial malleolus fracture. You can get a bimalleolar fracture, which is both of these malleolus mall malleola and we can get a trimalleolar fracture. So that is a fracture of the lateral malleolus, the medial malleolus and also the posterior malleolus. So those are a type of kind of ankle fractures that you can get. Ok. So what we need to be aware of as for your exams is what we call the Ottawa ankle rules. So these are basically rules. If you're unsure of whether you want to x-ray a patient to rule out an er an ankle fracture, you use these rules. So if you're uncertain, do we x-ray them or do we not x-ray them Um So it basically says that if there is presence of any of the features below, you want to do an extra. So if there's bony tenderness, the postera edge or tip of the lateral malleolar, sorry, the lateral malleolus hair, all there is bony tenderness at the posterior edge or tip of the medial malleolus hair or they are unable to weight bear both immediately and an ed for more than four steps, you want to do an X ray. So usually people don't really use this an Ed if they come in and you suspect an ankle fracture, you usually just send them for an x-ray, but you kinda need to know um for your exams. Um You don't really use art ankles like so when in cases where you can't use it is if the patient's intoxicated or uncooperative or have any other kind of painful injury, so it doesn't really work there. Ok. So what we also need to know is the Weber classification. So this is a way of classifying a lateral malleolus fracture. So the distal end of the fibular here. So basically the more proximal or the higher the fracture, the more unstable the fractures. So a type a fracture is below the level of the syndesmosis, which we mentioned above. And usually we manage it conservatively cos it's quite stable if it's a type B fracture. So it's at the level of the syndesmosis, we can either manage it conservatively or surgically I'll go through what conservative and surgical is. Management is in a bit weaver type C fracture, which is quite high up. And it's um sorry that that's a spelling mistake that should say above the level of syndesmosis. Um So type C fracture is above the level of syndesmosis and because it's usually quite unstable, we always treat it surgically. Sorry that, yeah, that should say that should say above. So type A is below the level of syndesmosis. Type B is at the level of syndesmosis and type C is above the level of syndesmosis type C being the most unstable. You wanna treat it surgically, type A being more stable, you can often treat it conservatively. Um So how do we manage it? So this is acutely. So when they come in, you want to assist the neurovascular status and with ankle fractures because there's a lot of nerves kind of running. Um within the ankle, you want to immediately reduce the fracture in ed, put them in a below knee back slab, which is basically a type of cast. And then after you do that, you want to assess the neurovascular examination after you reduce the fracture as well. Um So conservative management is a cam boot which we see up top here and usually that's for six weeks and you will also want to encourage weight bearing. Do you want them to pretty much walk? You don't want them to not walk. Um So what the cam boot does it kind of helps take some weight off the ankle. Um For surgical management, it's usually surgical fixation, often using plates and screws. So, oro which stands for open reduction, internal fixation. So we can see on the picture here uh the fracture, it's a type C with a fracture. It's above the level of the syndesmosis and you basically wanna treat it with um internal fixation or surgical fixation. Sorry. this picture is actually it's a bimalleolar fracture because it's can see disruption to the medial malleolus and lateral malleolus. Ok. Next, we're gonna cover knee injuries in particular soft tissue injuries. Um So the first thing we're gonna cover is an ACL or anterior cruciate ligament rupture. So it's a very common injury to the knee joint. There are about 30 cases per 100,000 people and the ACL. So what does the ACL do? Just some quick revision? It helps to stabilize the knee joint and it prevents anterior displacement of the tibia. So, if this is the um tibia, so if this is the femur and this is the tibia, it prevents this movement. So it prevents the tibia from moving forwards in relation to the femur. So the mechanism injury is usually an athlete with a history of twisting of the knee while weight bearing. So a sudden kind of changing change of direction um while twist uh of the flex knee and um features, it's usually very painful. You get rapid joint swelling and you get a sudden popping sound in the knee. So that's how patients usually describe it. The reason why you get rapid joint swelling. So within 10 to 15 minutes is that the ligament is actually very vascular. So it has a good blood supply. So you get a rupture, you get hemo arthrosis. So what we described below, so you get basically bleeding into the joint, so you get quite rapid joint swelling. So, on examination, um so you wanna do a knee examination and on examination, kind of the special tests you wanna do in this case, are Lachman's test or anterior jaw test. Uh So this is basically where you're trying to pull the tibia forwards and if it kind of move forward, so you place your two fingers or two thumbs on the tibial tuberosity and you wanna pull forwards while the knee is flexed. And if it, you see some kind of anterior displacement of the tibia, then the test is positive and it's highly likely there is an ACL rupture. Um So investigations, you wanna do an X ray just to rule out. So x-rays are very good for looking at bony damage. So any fractures, but they're not very good at picking up soft tissue damage. So an X ray wouldn't be used to diagnose it, but it's just to rule out whether there's any associated kind of bony injury or any fractures. Gold standard is you want to do an MRI. So MRI is very good at actually seeing the soft tissues. So, um yeah, you want to do an MRI, which can also pick up um meniscal tears, which we're gonna cover in a bit, um which are quite commonly associated with an ACL injury. So how do we repair it? So, initial management. So, any patient, um or all patients we want to do r so we want to get rest ice compression and elevation and we can then manage it surgically or conservatively. So, conservative management is basically you don't repair, um you want to just send them to physiotherapy, you want to rehabilitate them by increasing the strength of the quadriceps and kind of the surrounding muscles of the knee to basically help stabilize the knee. So there are a lot of other structures within the knee, a a lot of other ligaments that help stabilize the knee. So even if you do have a rupture of the ACL, it's not the end of the world. Um Yeah. So you can actually manage it conservatively. You don't always actually have to repair it or replace the AC um the ACL. Um But if you do want to, you do, you can repair it surgically. So how they do this, how the surgeons do this is they often take a tendon from elsewhere. They most commonly use a hamstring tendon. So they take a hamstring tendon out a hamstring tendon is quite long usually. And quite thin. So they like to fold it upon themselves quite a few times and you basically get a shorter but, um, quite thick tendon and then you drill a hole in your knee and basically you pull it through and you basically want to reconstruct your ACL. Um, so complications of this as posttraumatic arthritis. So whether you wanna do conservative or surgical repair, it depends on the patient themselves and the level of activity and also the extent of the in injury. So if someone is, let's say, you know, not very active, um doesn't live that, you know, not an athlete um that, you know, the, the you've like checked their stability, you know, there's still some stability there, then you can just manage it conservatively. But if you know, an athlete, um and you know, they do quite rely on having a very stable knee, then you might want to think of surgically repairing the ACL. Ok. So next, we're gonna cover uh a meniscus tear. So this is so the menisci just some quick recap on anatomy. So they are c shaped cartilage within the knee joint and mainly help with shock absorption. So the medial meniscus here is larger and is often attached to the medial collateral uh collateral ligament which runs kind of vertically up here. And the lateral meniscus is smaller and is not attached to any other ligaments. So the mechanism of this injury is usually a twisting injury while the knee is flexed and weight bearing. So similar to the ACL um as well. So the types of meniscus tears you can get are bucket handle, which we can see on the image on the side here. So it's a longitudinal tear like this. And that's the most common. You can also get different types of tears, vical transverse degeneration as well. But the buckle handle tear is the most common. Um in terms of features, you often get a tearing sensation in the knee, sudden onset of pain. However, in this case, the knee swelling usually develops over a longer period of time. It's uh 6 to 12 hours. This is because the meniscus doesn't have as good of a blood supply compared to the ACL. So the swelling develops over the uh time if there's a free body within the knee. So a bit of the meniscus that has completely torn off the knee actually can be uh locked in flexion. So how do we want to investigate it? So you wanna do a knee examination. In this case, the special test, you want to do that tests for a meniscus damage is what we call the mcmurray's test. So this is basically when you get them to lie flat on their back and you kind of get them to bend their knee towards you and you wanna push their knee kind of towards their chest at different angles. Um I don't have a video of this if you want to look it up later, you can. So mcmurray's test, so you just want to kind of push their knee backwards towards their chest at different angles while holding their foot. And if there's any clicking, locking or pain, it's a positive mcmurray's test. And um it's suggestive of a meniscus tear, however, like any soft tissue injury, a definitive diagnosis is an MRI and this is called standard. So how do we manage it? So it's an ACL you want to rice rest ice compression and elevation in a smaller tear, they can actually heal themselves. Um However, a large tear usually does require surgery. So the interesting thing about the meniscus is the outer portion of the meniscus usually has quite good blood supply. So it heals quite well. Whereas the inner portion of the meniscus has a poor blood supply and doesn't heal as well. So what does this mean for surgery is that if you have a tear kind of on the outer edge of the meniscus, which is a good blood supply, you can usually suture, suture, the kind of torn bit together. If the tear is on the inner third kind of of the meniscus, then uh which is a poor blood supply, you usually just trim it, you just um cut away the kind of torn part and this helps to reduce locking symptoms as well. Um something that uh you know, not very clinically relevant, but um you could get asked on as what we call the unhappy triad. It is um a frequent, uh it's in, it's three types of injuries that frequently occur together. Um usually in athletes that play basketball, rugby, football. So it's happens when you get a lateral force to the knee. When the foot is planted or fixated on the ground, you get a ACL tear, a medial collateral ligament injury and also a medial meniscus tear. So these so an ACL medial ligament and medial meniscus. So it's three injuries that happen altogether. So next, we're gonna cover some common foot conditions. So the first one we're gonna cover is a hallux valgus. So this is a bunion. So it's a very common foot problem. Um So it's prevalent in about 35% of people aged over 65 and it's more common in women. So what it is, it's a deviation. As we can see on the image here, it's a deviation of the great toe from the midline. So the great toe goes that way and it's associated with MTP joint subluxation. So, subluxation is kind of the one step before complete dislocation. So when a um bone pops out of its joint, so it's just kind of the the precursor to dislocation. So the features you usually get a very painful medial bony prominence here. Um The pain is usually aggravated by walking, weight bearing and shoes as well. So some shoes like heels can quite aggravate the pain um you can also get overlying inflammation or damage to the skin. So you can see that the skin here is quite red and investigation. It's usually a clinical diagnosis, but you can do an X ray to assess the level of deviation or subluxation. So how do we manage it? Usually this is um this can be managed by a podiatrist like so conservatively, you can give him analgesia or you can um give him you adjusted the footwear. So there's special types of footwear that can help um kind of try to correct it or reduce the amount of pain or if you wanna manage, manage it surgically, you can do a bunionectomy, which usually requires quite a long time to heal 2 to 6 weeks of healing. And there are various different procedures, um various different types of bunionectomies, but usually most of them involve some sort of osteotomy, which is the removal of the bone. So you want to remove part of the bone here and bring that toe back into alignment. So that's uh a bunion or helix valgus. So next, we're gonna cover achilles tendonitis. I'm a bit wary of the time. So it's already 751. So I'm going to speed through the next couple of conditions if that's ok. Um So achilles tendonitis slash tendon rupture. It's a very common cause of posterior heel pain. It's actually a spectrum of disease. So, on the milder side, you get tendinopathy, which is basically inflammation of the achilles tendon to a partial tear, to a complete rupture. So, risk factors include sports, involve jumping a lot. So things like basketball, um your antibiotics, something that's commonly tested in exams as well. So your fluoroquinolone antibiotics such as ciprofloxacin, um increase your risk of achilles, uh tendinitis and tendon rupture and also hypercholesterolemia. That's because cholesterol can um deposit into your achilles tendon. So features in tendinopathy or inflammation, you can get onset of um pain in your posterior heel, all around your achilles tendon usually worse on activity. You can get some stiffness and also some tenderness. Whereas if it's ruptured, it's uh um patients often describe an audible pop in their ankle. It's a severe and sudden onset of pain and they are in uh unable to walk because they can't plant effects. So your achilles tendon, basically your calf muscles gastrocnemius. So is attached to your posture heel um via your achilles tendon. So if you rupture that you can't plant a flex, so you can't walk. So what we do is it's usually a clinical diagnosis. Um on exam, one of the special tests you do is a simmons calf squeeze test. I'll cover that in the next slide and you can also do an ultrasound as well. An ultrasound of the achilles tendon. Um So how do we manage it? So if it's tendinopathy, you want to um give supportive measures to rest, give them appropriate analgesia physiotherapy to strengthen the surrounding muscles and you want to avoid giving them any steroid injections because that can actually increase the risk of a tendon rupture. So, if it has ruptured, so if they're present within two weeks, you want to give them analgesia and you want to completely immobilize them. So you don't, um, so they pretty much, um, you don't want them weight bearing on it at all. It's, uh, splinted in a plaster and you give them crutches as well. If it's within two weeks, you can um surgically repaired. So with the immobilization, usually, um it's for about 66 weeks. So you um basically, you want to immobilize it in kind of in stages. So you want to um if this is kind of your foot like this, you want to immobilize it firstly in equinus. So with your toes pointing, then semi equinus and then neutral. So it's um yeah, when you immobilize it, it's in the stages. So it allows it to heal better. Um So this is a simmons test. Basically, you get them to lie on the bed, put um put their knee on the bed, you basically wanna give their calf a squeeze. Um In normal patients, their um foot will plan to flex. So go will their toes will point if there's achilles tendon rupture, you see no movement. So that's positive. Um So it's suggestive of an achilles tendon rupture. Um So plantar fasciitis, this is a, a common cause of heel pain. Um Most common cause of heel pain in adults usually worse around the medial side develops due to chronic overuse, um causing microti and uh and then cause of recurrent inflammation. Risk factors include weak plantar flexes. So your weak calf muscle and also prolonged standing or running as well. So features you get heel pain worse in the morning, gets better throughout the day. Usually on the medial side of the heel and often associated with a tight achilles tendon. So how do we manage it? We want to rest where possible. Um You want regular nsaids to kind of reduce um inflammation but um be aware if you do give someone regular NSAID s, you wanna give them PPI cover um footwear, you want to support, um you know, you want, you want good arch support, you want cushioned heels, do physiotherapy and in this case, you can try corticosteroid injections to help reduce inflammation. So, next, uh so lastly, the last thing I wanna cover today is osteoarthritis, which is a very common condition. Um We're gonna cover osteoarthritis of the hip and the knee. So, osteoarthritis is a very common joint disease worldwide. It's commonly described as degenerative joint disease. So, wear and tear. Um So most commonly affects the large weight bearing joints. So things like your knee and your hip, but it can also affect your hands. Um Risk factors include obesity, uh repetitive trauma. So that can be through your occupation or if you do sports. So it's just wear and tear over time, age and also female gender as well. So, the pathophysiology behind it is you kind of constant wear and tear, kind of degrade the cartilage, get remodeling of the bone due to active response of chondrocytes. The chondrocytes are the cells that produce your cartilage. And also you kind of get release of infl inflammatory cells. You can get also localized inflammation as well. So, features include pain and stiffness of the joints, pain that is characteristically worsened by activity and relieved by rest. Um This is in comparison to rheumatoid arthritis, which actually pain gets better with activity and worse with rest. Um you can get a reduced range of uh movement and you can also get deformities as well. Symptoms are usually unilat true. Whereas in rheumatoid arthritis, you get bilateral symptom and if there is any stiffness in the morning, it usually lasts for a few minutes as opposed to rheumatoid arthritis, it lasts for an hour or so or more. And so investigations usually clinical diagnosis but x-rays can be used and on x-rays, um uh most of you uh might have heard of the loss pneumonic. So this stands for loss of joint space, osteophytes, subchondral sclerosis and subchondral cysts. So, on X ray, you can see on the right side, uh on the left side is normal, on the right side is osteoporotic. So you can see kind of on the medial side or here you get loss of joint space. You get osteophytes here, which are pretty much bony outgrowths due to bone remodeling. You get subchondral sclerosis, which you can't really see here, but usually underneath the cartilage, you base uh it gets more white so it's remodeling. So those areas are more dense and you get sclerosis. Um So whitening of the bone underneath the cartilage and you also get subchondral cysts which you can't see over here, but it's kind of you get like punched out lesions of bone. So, um yeah, subchondral cyst as well. So, osteoarthritis of the knee. So the most commonly effective joint is the knee. So risk factors are genetics. Um age female, gender and obesity. You get pain around the knee that can radiate to the thigh and the hip. It's usually worsened by exercise and relieved by rest and stiffness. Uh you can get bilateral disease in this case and you get reduced function. And if there's severe, you can get reduced range of motion, you get joint crepitus as well. So investigations you can do an x-ray. So how do we manage it? Lifestyle modifications. You want them to lose weight, uh increase uh uh exercise, um or exercise in moderation or how much the pain will allow them um to do uh smoking cessation, you wanna give him analgesia. So, oral paracetamol and topical nsaids. So, the knee is one of the joints where you can actually give him some topical nsaids to rub over the area and physiotherapy to strengthen the muscles once again and also steroid injections as well. So, so that's kind of conservative management. You can manage it. If there is severe disease, you can manage it surgically. So, in advanced osteoarthritis, you can do a knee replacement, but like your hip replacements, as we described before, they don't last forever, they usually last for 10 years. So you kind of want to weigh up the pros and cons of doing a knee replacement. Um If the disease is localized to one compartment or the other, you can actually do a partial knee replacement. So you can um replace either like the medial or the lateral compartment. This usually has a faster recovery time. Um Lastly just the last slide before we finish. So this is osteoarthritis of the hip. It's the second most commonly affected joint after the um knee. Uh same sort of risk factors features. In this case, it's pain in the groin and get stiffness that improves with mobility on examination. You can get an antalgic gait which is basically a limp. Um They can walk uh and they often get a reduced range of motion. If it's severe, you can get uh a fixed flexion deformity. Um This can be tested for by the Thomas test which is uh we can see on the uh the image up top. Um and investigations you can do an X ray and show the same kind of features. You get reduced joint space, subchondral sclerosis and some osteophytes as well. So, how do we manage it? You can do conservative management. Same thing above give him pain medications. Top, uh, you can give him oral paracetamol, um, surgical management. You can do a hip replacement. Um, but same thing you wanna be worried. They don't last forever. So, weigh up the pros and cons, um, complications of surgery. VT So uh bleeding infection, dislocation, loosening and hip replacements. Yeah, they last 15 to 20 years and they may require revisions. So, yeah, that's it. So, thank you very much for listening. I think we're all done. Hi, everyone. Sorry about that. I don't know what happened to my audio and camera. It just wasn't working. Um Thank you so much for attending. Um, in terms of the feedback, the feedback link has been posted on the chat. Um, fill out to get your attendance certificate and um yes, you will get the slides, the slides are attached to the medal link. And again, um if you've attended the talk to fill out the feedback, you can have access to the slides. Um Thank you so much for attending and thank you George for that amazing talk, which is also so clinically relevant and um lots of the important clinical features you'll need for your and exams. Um If you have any questions, put them in the chat and thank you guys all so much.